Good afternoon to everyone. I’m starting this new post by saying that this one will stray a bit from the normal purpose of this website. It will not contain IMAT tips, info about Pavia’s classes or facilities, or anything like that. I would like to share with you all one of the many experiences I’ve had here; this one in particular is dated November 25th, so, if you wish, read it as if it had been written on that day.
It’s been three months and a half since I moved here to Bruxelles and 23 days since I started my first clinical rotation in the ER of a rather large hospital here; Monday to Friday, 8.30 to 17.00, with 10-15 minutes of lunch break when there are few enough patients to be able to go and grab a bite.
One cool thing here is that students are also assigned to guard duty overnight (5 p.m. to 8.30 a.m.) or during the weekend (9 a.m. to 9 a.m.): in both cases, 24 hours straight, with the possibility of getting some 3-4 hours of sleep as there are two students/interns who can split the night. It’s a great chance to learn as there are less doctors than usual, meaning they rely more on students to do a part of the job: visiting the patient, taking the history, doing a first physical examination, and checking lab results when they come out; furthermore the ER interns are occasionally called if there are minor emergencies in other hospital wards to make a preliminary assessment of the patient. To make all this even better, students are paid to do that (not much, but having done three guards here I’ll basically cover most of the expenses for my next vacation).
However, today (and yesterday) my stage is a bit different: I get the chance to spend my day on the SMUR. The Service Mobile d’Urgence et Réanimation is a vehicle which is manned by a nurse and a doctor, both trained in emergency medicine or intensive care; as far as I know there is no real equivalent in the US or in the UK, where mostly paramedics, EMTs and nurses are deployed, while countries like France and Italy have similar vehicles (we call it “automedica”). Normally students are not allowed to go on the SMUR in the hospital where I’m doing my rotation, so we can say I was a bit privileged. Lucky me.
I must be there at 8, so I get up at 6, have a huge breakfast, take a hot shower and go out; it’s 2-3° and windy outside, so I walk fast to my tram stop and catch it just in time. The only problem for today is that the SMUR is in one hospital, and I have my guard duty in another hospital of the same group (which is where I generally have my stage); there is a shuttle between the two every hour, and I hope I’ll be able to take the one at 4pm otherwise I’ll be incredibly late.
A 40-minutes ride later, I get off just a hundred meters away from the hospital. Since it’s my second day and I already know where to go, I hurry inside and get changed in the yellow-and-green suit they gave me; I barely have time to go to the doctors’ room in the ER that the SMUR phone goes off. I meet the doctor and nurse that will be with me today: the first is German, the latter is Flemish. A nurse in training – French guy, about my age – joins us too: we’re a four-man team, which at least is good if there are weights to lifts. Off we go, siren screaming, in the cold of a Belgian morning.
We arrive at the patient’s house: he’s a middle-aged man, who had been constipated for a few days when he decided to take a laxative; ever since he’s been having a severe abdominal pain and episodes of vomiting; the firefighters arrived and saw him like that, and thought best to call the SMUR (that’s how it works in Bruxelles: firefighters often are the first on the spot). The doctor examines his abdomen, and I follow: the patient jumps from the pain as soon as I touch him, and his belly is all stiff. The doctor (we’ll call him dr. A.) takes a brief history while the nurse takes a blood sample and puts an IV, but in the end, with an acute abdomen like that, the patient will need a CT scan and likely surgery. The firefighters bring the patient down to the street on a chair, they put him on a stretcher, and get him on the ambulance, while dr. A and I go up with him.
We arrive at the ER where a physician takes the patient in charge and gets him ready for CT, while I go back to the doctors’ room and settle down for a moment. There are a couple new patients arriving and a nurse asks me to go see the first, and like this I spend another hour or so.
The phone rings once more at 10.30, and we leave; we know it’s a trauma, that the firefighters and a nurse are already there; we arrive in a large gym where a man is lying on the floor surrounded by 10-12 rescuers between ambulance personnel, firefighters and acquaintances. A woman is holding his lower limb by the knee, the feet and lower half of the leg dangling in the air and covered in blood – tibia and fibula fracture which slightly breached the skin. He’s not even that much in pain, but dr. A cannot feel his pulse on the foot so he must reduce the fracture; after a few minutes under morphine, the patient has his feet pulled and an ominous crack is heard as the fragments go back in place. The patient doesn’t feel a thing, sedated how he was, but the poor guy won’t be able to do sports for a long time. We bring him back to a nearby hospital and leave to go back to our base, but while on the road the radio creaks that we’re requested to head somewhere in Zaventem for a child who fainted.
Zaventem is one of the districts that make up the Region of the Capital Bruxelles, from which takes the name the airport which was hit by terror attacks in March this year. I didn’t dare ask, but I had noticed earlier that morning that on the jacket of both dr. A and our nurse-driver there was a patch commemorating the attacks; they start telling us something about them, like how they had been among the first on the scene, but they never really fall into details and we’re arrived before we can hear more about it. We find the child and her mother with him, but there’s a small problem: they’re Flemish, and he speaks only Dutch.
You see, Belgium is this strange place which is divided in two main regions (Wallonia and Flanders) each with its own language (French and Flemish/Dutch), plus a minority of Germans. It’s not infrequent that someone from one side of the country understands only one of the two languages, and since Bruxelles is officially bilingual and sort of “the center” of the country, people from both sides live there and may not be able to communicate with each other.
Our nurse speaks to the family and we reach the conclusion that the child is ok and just had a panic attack, so he’s taken the hospital by the firefighters while we head back our way. The day goes on with a hypoglycemic crisis (about which we speak at lunch – amusing coincidence) and a BPCO crisis. We go back from the last mission at 15.40, just in time to take my shuttle at 16. I grab my stuff, say goodbye and thank you to everyone, and head out of the hospital. I get on the bus and take the chance to rest because working for 8 hours straight is, without a doubt, tiresome.
Another 40 minutes later I arrive at the other hospital, I grab some frites (Belgian fries are amazing, trust me) from the booth at the entrance and eat them on the way to the ER. I go in, get changed in my scrub and white coat, and join the others in the doctors’ room, where the physicians from the day shift are passing over their patients to the night staff. The chef de clinique sees me come in and asks me: “Stefano! Did you just see the psychiatry patient?”.
There is a room in the ER reserved to psychiatric patients, who are 99% of the times physically healthy and so are left for the students to examine; I say I just arrived. He replies: “Ok, then… can you please go and see the psychiatry patient?”. I leave the bureau while all the other doctors say “Bienvenue Stefano!”, joking merrily. Talk about a slow start.
In ten minutes I’m back and things gradually settle down to what will be the night shift. Six colleagues remained: two residents and four PGs (post-graduates, in their first year of specialty training in Emergency Medicine), two of which will leave at 10pm; I know all but one resident, and they’re all easy-going and good at what they do, so we’re relaxed; there is also another student whom I have already done a guard with: he’s motivated to work and is really a nice guy, meaning I’ll be in good company for the night.
I go see my first real patient: she’s a young Iraqi girl who’s moved to Belgium recently; she doesn’t really speak French but she has a good English. She tells me she’s been having diarrhea for a few days and now she’s feeling dizzy; furthermore, she complains of feeling something moving in one of her toes, and she thinks it’s a worm, so… wait, what? I reassure her that her dizziness is very likely to be caused by the loss of fluids, and after examining her I really do inspect her toe and try so very hard to remain serious. Finally I do feel something moving: her pulse. With a mental facepalm I leave and report everything to one of the resident, who later sends the girl away with a course of antibiotics.
I don’t do that well with the second patient: she’s younger than me and already with a chronic renal failure; she did a pregnancy test a few hours ago and it turned out positive, but now she really doesn’t know what to do because her doctor clearly advised her against having more children: she already has one which is there in the ER with her, together with her smaller sister.
Her sister’s a big talker, and asks me a lot of questions; at some point, she addresses me as “Monsieur” and asks me why my French accent is a bit bizarre; after hearing that I’m not a native French speaker (who would have guessed! I’ve been learning French only for two years.) she asks me where I come from. I tell her that if she takes the child for a walk while I visit her sister, I will answer her question; she goes, I do my job, but before I leave the patient asks me very seriously not to reveal to her sister the results of the pregnancy test that was going to be done in the hospital to confirm whether she was with child or not.
I finally leave the patient’s room as the younger girl is just coming back through the corridor. I pass by her smiling and reveal her I’m Italian; she doesn’t believe me at first, it’s always like that. On the contrary, I’ve been asked rather frequently if I were Flemish.
I return to my PC to check the results of the blood sample: bHCG, which is the thing detected in the urines for common pregnancy tests, is about 90000 -> Totally pregnant. I report once again to the resident (we’ll call him dr. D), and he goes to talk to her; first thing he says after entering the room is: “The test was positive, you’re pregnant”. Just in front of the sister. The patient incinerates me with her eyes; I wait for dr. D to finish speaking, then leave as fast as I can, my cheeks on fire. Damn.
It’s now almost 10pm and things have been calm for some time. Dr. D’s phone rings: it’s a SMUR calling to warn they’re arriving with an 89-years-old patient in respiratory distress. A few minutes later the entrance door to the ER slides open and two firefighters and the SMUR doctor come in with a stretcher; on board is M.me S., a very sick woman with her eyes closed and an oxygen mask on her face; she’s breathing heavily, and every breath is accompanied by the unequivocal gurgling sound of pulmonary edema: her lungs are filling with water because the heart is not able to pump the blood out, so this accumulates upstream; pressure builds up, and the blood is filtered into the airspaces.
Dr. D and I accompany M.me S. to the resuscitation room, while two nurses set up IV lines and prepare all the material to intubate her. They’re all ready to go when the SMUR doctor stops them. She had spoken to the son who also is a physician, and he had been quite clear: she’s very old, always bed-ridden – it’s DNR (Do Not Resuscitate); no intubation or other invasive procedures, only hydration and medical therapy.
M.me S is visibly cyanotic and her blood pressure floats around 60/40. Dr. D starts her on atropine to keep her heart going and puts on a NIV device (non-invasive ventilation) to guard her oxygen at an acceptable level; in a couple of minutes, parameters move back towards normality. She seems stable now, albeit not at all well (at lung auscultation she crackles like crazy), so we leave the room to request all the necessary examinations, while the nurses take some blood samples, insert a urinary catheter, and start cleaning the patient.
I know I’m not too useful there; I go and see a couple more patients who are not really sick (including one who thought her headache and foot pain must have been connected), but in between things I slip into the resuscitation room to see how it’s going. At about midnight an alarm goes off from M.me S’s room and I head back in together with dr. D and one of the nurses. Her blood pressure has fallen again at 60/40 as the effects of the atropine have worn off, and her oxygen saturation is dropping too. She looks in pain, with her jaw clenched and a frown on her forehead.
The intubation material is still there on the table, and we’re still legally prevented from using it. The nurse looks at dr. D, then looks at me; she asks: “What do we do?”. Her voice is almost pleading, she knows the woman is not going to last long.
I’m generally rather proud of how well I’m normally able to react under pressure, and maybe I shouldn’t have felt anything considering I wasn’t going to be making any choice; however, I can’t even start describing what I felt in that terrible second when the nurse was looking at me over the dying woman and asking: “What do we do?”.
Dr. D decides for a more aggressive fluid repletion and insists with the atropine to try and get her pressure up; a couple of minutes later we see he did the right choice as the patient’s BP is a flourishing 150/90. It’s still too early to claim victory, as the blood tests come out: she has both liver and renal failure, and increased markers for pulmonary embolism; she might have had an acute hepatorenal syndrome, which is often a deadly condition. Still, not a single drop of urine has traversed the bladder catheter; things are not looking good; but at least she’s stable again.
I leave the room and the other intern and I glance at each other: we both recognize a tired look on the other’s face and we decide it’s time to split the night; we’ll go to sleep at one, and if they need us somewhere in the hospital he’ll wake up if before 5 a.m., while I’ll do if later.
No new patient is arriving, so I just sit down to rest a bit and check occasionally on our woman. At about 1 p.m. I get into her room and find dr. D standing there in the dark, his face painted blue by the monitor screen. He’s a tall, dark-skinned man from Eastern Europe, a bit gruff in his ways but calm and considerate. I approach him and we discuss for a couple of minutes about the patient, talking in a low voice as for fear of waking her up; we’re both quite pessimistic as M.me S still didn’t show any sign of improvement. He turns on the lights to take one last look at the woman, when something yellowish catches our attention; never have I ever been so satisfied with seeing a trace of urine flowing inside a catheter. This means her kidneys are restarting and she’s no more severely hypovolemic. I decide to go to sleep on the wave of this success, so I say goodnight and head for one of the rooms reserved for interns two floors above the ER. Dead tired, I set my alarm at 7 a.m. and throw myself under the bedsheets.
I wake up and am amazed to be hearing my phone alarm and not the ringtone. I quickly get up and go downstairs to see how the M.me S is doing: still stable. Nothing major happened during the night, and the urine flow stopped as soon as I left, which means she didn’t get worse but she didn’t improve either. I eat two toasts with ham for breakfast because I’m starving, and head back to the doctors’ room, where dr. M., a PG, is yawning and drinking a coffee. She asks me what I’m doing already up. I know I could have slept until 9, but I didn’t want to leave for too long while M.me S. was doing so poorly; instead of saying that, I lie that I always wake up early anyway.
The last two hours pass and I visit one last patient. The doctors from the Saturday shift arrive one by one and we all exchange greetings; I listen as dr. D, who had woken up an hour earlier, reports M.me S.’s case to his replacement. The night has been quiet, so the process is rather quick and in twenty minutes I’m out. It will be someone else’s job to look after the patient, although I make a mental note to check her dossier on Monday when I come back.
Dr. M walks out of the ER with me. She’s Italian and she’s moved to Belgium for her specialty; she lives close to where I do, so we go and take the metro together. We chat casually about what brought her here in Bruxelles and what she thinks of the city. She tells me she’s doing good and she’s happy, but she misses home sometimes; she’s conscious of the fact that, year after year, she will have more work to do and fewer occasions to go back to Italy, and she’s okay with that. On the metro I start feeling sleepy again and I tell M. I’m hungry; she opens a pocket in her bag and takes out a bar of chocolate, which she hands me.
I accept the bar and start chewing it, stopping just a moment to consider the past 24 hours. Yes, it’s been a good day. And I love Belgian chocolate.
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